In December 2019, a novel β-coronavirus emerged in the Wuhan, China, causing pneumonia-like illness. Later, this virus was identified as the severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV2), which caused a widespread flu-like respiratory disease, and was named the Coronavirus Disease 2019 - COVID-19 (1, 2). On March 11th, 2020 , the World Health Organization (WHO) declared COVID-19 as global pandemic (3)
The reported mortality rate varied from country to country, from 7.2% in Italy to 2.3% that has been reported in China (4). Until April 28th, 2020 the total number of people who have been infected globally reached more than 3 million, with more than 200 thousand fatalities. On the same date, Bosnia and Herzegovina (B&H) reported 1,585 individuals with COVID-19, of which 63 people had deceased (5). The first COVID-19 positive case in B&H was documented on March 17th, while in the Tuzla Canton, Northeastern part of Bosnia and Herzegovina (population 477,000) the first registered case was on March 28th, 2020. This is comparably late for the first registered infection when taken into account other European nations, which had earlier detections of COVID-19 infection. In the period between 28th of March 2020 and 27th of April 2020 there were total of 90 patients positive for COVID-19 with 25 hospitalizations in Tuzla Canton (6). Interestingly, this coincided with the near end of the flu season and was 14 days after lockdown measures were introduced in this part of B&H (social distancing measures due to COVID-19 were imposed on 14th of March). It is also worth mentioning that after 27th of April this region did not have any new reported infections for 44 days. Furthermore, this is the first article that has analyzed hospitalized patient with COVID-19 in B&H and assessed the length of hospitalization (LOH) of these patients as of yet and can provide insight into the nature of COVID-19 in this part of Europe (6-8)
SARS-CoV2 is an RNA virus, from the family of the coronaviruses. Coronaviruses were first identified in the 1960s, and since then, seven of the coronaviruses are known to infect humans (9). Usually, coronaviruses cause mild flu-like symptoms and these viruses are transmitted when infected droplets come in contact with the mucous membranes of a susceptible human host, this can be either directly through person to person contact, or indirectly through contact with contaminated surface. Conjunctival tears, saliva, urine and stool are also being considered as possible pathways of infection of COVID-19. The process of virulence with COVID-19 is initiated when SARS-CoV2 viruses latch on receptors of the Angiotensin-Converting Enzyme 2 (ACE2). Different levels of ACE2 among population groups were speculated as a reason behind the range of severity of inflammation. Individuals wiht COVID-19 infection experience formation of hyaline membrane that increases the thickness of the alveolar wall, consequently reducing O2 exchange in the lungs (10).
Association of obesity (BMI >30) and severe clinical presentation in COVID-19 infected patients is currently being investigated. The mechanism on how obesity correlates to more severe outcome could be explained by the substantial respiratory system compromise paired with increased airway resistance, impaired gas exchange, a lower lung volume and weaker respiratory muscle strength. Furthermore, obese patients are more likely to suffer from health conditions such as cardiovascular disease, insulin resistance and metabolic imbalances, all these facts place obese patients at risk of a more severe COVID-19 course. The risk of mortality in obese patients was recognized before COVID-19, where in the previous influenza pandemics of H1N1 and H1N5, patients with a higher BMI were more likely to have lethal outcome (11, 12). In a retrospective cohort from France which included 124 patients admitted in the ICU, most of the patients who required invasive mechanical ventilation were obese with a BMI above 35 (85.7%), and they concluded obesity to be a risk factor for severity of the diseases (14). Similarly, in Shenzhen, China, 32% from 383 patients with COVID-19 were overweight, while 10.7% were obese. Those who were obese had 2.42 higher odds of their disease progressing to severe form (13). Moreover, a more extensive study from New York that included 4,103 COVID-19 positive patients showed that BMI >40 was a negative predictive factor for sever form of illness. In case of children, BMI-for-age can produce clear picture with regards to weight status of the patient and is used for children older than 2 years of age (15).
According to the CDC, older age groups as well as any age group with known comorbidities were found to have a higher risk of developing severe from a SARS-CoV2 infection. Comorbidities that were reported to be associated with severe form of COVID-19 were moderate to severe asthma, chronic lung conditions, diabetes, serious heart disease, kidney disease undergoing dialysis, chronic liver disease, cancer or immunocompromised individuals (16).
This report aims to analyze first 25 patients who tested positive for COVID-19 in Northeaster part of B&H and whose clinical condition required admission to designated COVID-19 clinic at Tuzla University Clinical Center, Bosnia and Herzegovina and the impact of different clinical characteristics and admission factors on the length of hospitalization (LOH). These patients were followed from admission to discharge. Further exploration of their clinical characteristics will be elaborated as a full understanding of the disease is still limited.